Facility Evaluation Report

On 03/13/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent case management visit at the above facility. LPA met with Administrator Kelli Pinkney and explained the purpose of the visit was to deliver findings on the Department's investigation regarding a staff on client incident that occurred on 11/28/2023.

The investigation consisted of the following: On 11/30/2023, Licensing Program Analyst (LPA) Regina Cloyd conducted a case management visit. LPA reviewed clients and staff records and requested for the administrator to provide Staff#1 (S1) and Client #1 (C1) records electronically. LPA also requested for an electronic copy of the Personnel Report (LIC 500) and a copy of staff schedule for three months (September - November 2023). One staff and one client was interviewed. On 11/30/2023, Investigator Sonia Sandoval started her investigation which included request for records, record review, and interviews with witnesses, clients, and facility staff.

The investigation revealed the following, The interview of C1 revealed S1 headbutted, pushed C1 against the wall, picked up and slammed C1 on the floor. The interview of Staff #2 (S2) revealed during the unprovoked incident, S1 used profanity while addressing C1 and physically assaulted C1 (headbutting and slamming C1 on the floor). The interview of S1 revealed S1 failed to accept culpability for the incident, confirmed S1 failed to follow the facility protocol to refrain from engaging with agitated clients and confirmed C1 sustained the injury (fractured clavicle) during the incident. The review of the police report revealed C1’s and S2’s statements of the incident were consistent. Client C1 sustained an injury (fractured clavicle) when S1 physically assaulted C1 while in care. The preponderance of evidence has been met therefore the allegation that staff physically abused client while in care is substantiated.